Infection Prevention Stephanie Langdon, MSN, CIC Infection Control Practitioner Presbyterian Novant Health Charlotte, NC

Medical asepsis vs. Surgical asepsis Asepsis the freedom from disease causing microorganisms. Two types Medical and Surgical. Medical asepsis practices intended to confine a specific organisms to a specific area. Can be clean or dirty. Surgical asepsis or sterile technique practices intended to destroy all microorganisms

Types of Microorganisms Causing Infections Bacteria (MRSA and VRE) Viruses (Flu and Parvo) Fungi (Aspergillus) Parasites (Intestinal Worms)

Germs live everywhere! Most microbes that live in our environment perform functions essential to our survival, a small percentage of them enter our bodies to cause an infection, and a smaller proportion cause a drug resistant infection. Because microbes have extremely high replication rates, they can also mutate quickly to enable them to adapt to changing conditions.

Bacteria Most common infection causing microorganism Lives on your skin and surfaces Can live and be transported through air, water, food, soil, body tissues and fluids.

Staph Aureus to MRSA In the beginning Staph Aureus Emergence of MRSA (1960’s) Emergence of CA-MRSA (1990’s)

Terms You Might Hear Community Acquired MRSA (CA-MRSA) Methicillin-Resistant Staph Aureus (MRSA) Hospital Acquired MRSA (HA-MRSA) Methicillin-Susceptible Staph Aureus (MSSA) Colonized MRSA Infected MRSA

CA-MRSA Control Measures Also Try to Prevent Know the difference between Cleaning and Disinfecting First you clean then you disinfect Use correct products Skin Surfaces 8

Disinfectants that Kill Germs on Skin Alcohol based hand Sanitizers Antibiotics Soaps and wipes made for skin Good old soap and water (Doesn’t have to be antibiotic soap) 9

Disinfectants that Kill Bacteria on Surfaces Sani-wipes (Kill time 10 minutes) Virex (Kill time 3 minutes) Dispatch (Kill time 1 minute) Bleach kills everything (see handout)

Ultraviolet Waves Ultraviolet waves are effective in killing bacteria and viruses. Hospitals use equipment that produce these waves to sterilize equipment, water and air in rooms. It is also used to treat acne and psoriasis. These are the same waves used in tanning beds.

CA-MRSA Control Measures Cover all wounds Train athletes in first aid for wounds and signs of infection Encourage Good hygiene Practices Discourage sharing of items Establish routine cleaning schedules for shared equipment Encourage players to report skin lesions

Investigational Findings Increase number of Spider Bites reported in the Emergency Rooms cultures revealed MRSA. CA-MRSA median Age is 23 HA-MRSA median Age is 68 (Naimi, T.S. et al. JAMA 2003, 290:2976-2984.)

Hospital vs. Community Acquired Infections Hospital (Nosocomial) Acquired MRSA : defined by the CDC as MRSA acquired after 48 hours stay in the hospital with no previous documentation of a positive MRSA culture Community Acquired MRSA: defined by the CDC as MRSA acquired in the community. If we test within 48 hours of admission and patient is positive this is a community acquired MRSA

How to Recognize an Inflammatory Response 1st Stage: Vascular and Cellular Responses 2nd Stage: Exudate Production 3rd Stage: Reparative Phase

Types of Infections Colonized: defined as a carrier of the bacteria but you are not sick. Cultures (screening) are from nares or perirectal area. Infected: defined as someone with a wound (infected area) that has been cultured and is positive for an infection

Off the Beaten Path VRE - Vancomycin Resistance Enterococus C diff- Clostridium difficile or CTOX ESBLs - extended-spectrum beta-lactamases (which are resistant to cephalosporin's and monobactam’s)

Chain of Infection (Six Links) Etiologic Agent (Microorganism) Reservoir Portal of Exit from the Reservoir Method of Transmission Portal of Entry to the Susceptible Host Susceptible Host

Isolation Types Airborne Droplet Contact Contact Enteric

Isolation Precautions Airborne to prevent the transmission of highly contagious or virulent infections spread by small airborne droplets (smaller than 5 microns) examples know or suspected TB, chicken pox. Droplet to prevent the transmission of diseases spread by large droplets (larger than 5 microns) Examples are meningococcal meningitis, pertussis, mumps

Airborne Precautions Disease requiring Airborne Precautions: Mycobacterium Tuberculosis (MTB) Measles Other significant diseases (i.e. Pandemic Influenza) For a complete list of diseases/conditions requiring Airborne Precautions see Appendix A 1 (Linked to CDC). N 95 respirators or PARA are required for all employees upon entry to an Airborne Precautions room. We do this for Every Patient, Every Time! Monitored Negative pressure is Required During the pandemic influenza period we encouraged staff to use their N95 per shift but they had to wash their hands before they put the mask on and before they took their mask off. We also wanted them to use face protection. They could kept their mask in brown paper bags and discard at the end of the shift. Anyone that engaged in aerosol generating activities (e.g., collection of clinical specimens, endotracheal incubation, nebulizer treatment, bronchoscopy) should discard mask after each use.

Signs and Symptoms of TB Night sweats Coughing up blood Weight loss Why is a positive PPD not always a sign of TB. What does the chest x-ray look like? Are the sputum's that are collected every morning for three consecutive mornings positive for Acid Fast Bacilli?

TB Mycobacterium tuberculosis (MTB) All other Mycobacterium’s can be called MOTT (mycobacterium other than tuberculosis) Other Pulmonary Mycobacterium’s Mycobacterium avium complex MAC , M. kansasii, M. absessus, M. xenopi Skin Mycobacterium’s M. marinum Wound infections M. fortuitum, m. chelonea and m. absessus

Genus Species Genus Mycobacterium (ALL Fords) Species M. Tuberculosis (Lincoln Continental) M. Avium (Mustang) M. kansasii (Taurus) M. absessus (Fusion) M. xenopi (Fiesta) They ALL test positive for Acid Fast Bacilli

Special Airborne/Contact Precautions This category is for diseases that can be transmitted to others through both the airborne and contact route. Examples include: Varicella Zoster Virus (VZV): Chickenpox and disseminated zoster/shingles SARS-CoV Disseminated means on more that one dermatone. An example of this would be if a patient has a rash on their stomach and on their face. Another example would be if a patient has a rash on both sides of their back. If in doubt call Infection Prevention.

Shingle Questions Who is considered immune? Immunity comes from having the chicken pox or having the VZIG. How do you know if the patient has zoster pneumonia? Positive sputum’s would be needed to verify the present of the herpes virus and CXR positive for pneumonia. If the patient is positive for zoster pneumonia and has visible lesion on more than one dermatome is this considered disseminated zoster shingles or is it only localized? Consider disseminated zoster shingles.

Droplet Precautions Most frequent diseases we see: Pertussis (Whooping Cough) Neiserria Meningitis Parvo (5th disease) Flu Our current practice for Flu patients is for staff to wear surgical mask. This may change pending further recommendations by the CDC. Everyone else must also don a surgical mask upon entry to room.

Bacterium Meningitis B for Bad Neiserria meningitidis (Treat intimate exposures as well as patient) Only treat Patient Hemoplus influenzae Streptococcus pneumonia Streptococcus group B L. monocytogenes

Isolation Precautions Contact to prevent the transmission of potential diseases that are spread by close, direct, or indirect contact. Examples are MRSA, VRE and ESBL. Contact Enteric same as contact but to remove bacteria have to wash hands with soap and water. Examples C diff.

How it is Spread The primary method of MRSA transmission is by Contact, usually from people's hands. The organism has been recovered from people's hands after they have touched contaminated material and before they have washed their hands. The MRSA organism also is found among health care workers who carry the organism either in their nose or on their skin. If a person carries MRSA in his or her nares, it can be transferred to patients by hand contact.

C. difficile: Do NOT Use Purell Hand Sanitizer Use soap and water if you suspect the patient has C diff or is diagnose with C diff. If you only have waterless hand sanitizers you can use it until you can get somewhere that you can wash your hands with soap and water. Any one with diarrhea could have c diff. The rooms have to be cleaned with Clorox to kill the spores. Housekeeping managers gets a sheet daily of the rooms that positive c diff patients occupy. Yes they get a list of patients with c diff but if you take the signs down before your EVS staff has been informed this could lead to miscommunication. So please be thoughtful of others working with the patients.

When to use PPE (Personal Protective Equipment) When it is warm Wet Not yours

Which is More Dangerous? Hand Hygiene Initiative Which is More Dangerous? Great White Shark (Carcharodon carcharias) Which kills more lives??? Answer is MRSA MRSA (Methicillin Resistant Staphylococcus aureus)

We Know What To Do!